Baseball Diamond Concept for

Port Position in Laparoscopy

Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore
 Where should I insert the port?

First query and common problem which the beginners encounter

Common cause of stressful surgery is wrong port position

If one port is at wrong place, surgeon will struggle throughout surgery due to bad
ergonomics

May be sometime one of causes of complication and more rate of conversion

Answer lies in Baseball Field
 Primary/Optical Port
(Telescope)

Outer Arc

Inner Arc

Working/Secondary
Port

Working/Secondary
Port Target of Dissection
First Principle of Baseball Diamond
Concept

Half of the instrument should be in and half out.

 1st Rationale for 1st Principle

Laparoscopic instruments works on Lever action.

Type I Lever……….Fulcrum in the center and load is equal and opposite to the force
applied
Generally all laparoscopic instruments should behave like type 1 Lever
 1st Rationale for 1st Principle

If fulcrum is very close to load arm:

i.e. maximum length of instrument outside (Port very near to target of dissection)
Force is magnified……………leading to tissue tear or avulsion of CBD
movement will be rectified.
 1st Rationale for 1st Principle

If fulcrum is very close to force arm:

i.e. maximum length of instrument is inside abdomen (Port very far from target of
dissection)
Little movement outside leads to magnified distance moved inside  again leading
to collateral damage(diaphragm, bowel) i.e. overshooting
Force will be rectified inside.
 2nd Rationale for 1st Principle

If port is very close to target of dissection………………elevation angle will be 90O

……surgery can’t be performed….as instrument will not lift the tissue e.g. fork at 90o can’t
turn the omelette

If port is very far from target of dissection………….elevation angle will be less i.e.
10o……handle of instrument will touch the body of the patient

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Elevation Angle = angle between instrument and body of patient

Ideally it should be 60o and equals the manipulation angle
during cooking, stirring etc 60o elevation angle is used
 3rd Rationale for 1st Principle

If port is very close to target of dissection………metallic cannula of port will touch

the non insulated part of instrument….direct coupling occur….injury to nearby
bowel or bladder

If port is very far away from target of dissection…………………entry and exit will not
be witnessed by telescope as cannula will be behind the telescope and long
pathway of entry/exit is blind and bowel damage may occur

If half is out and half is in………no chance of direct coupling and no blind long
pathway
 How to get 1st Principle?

Step I: Find out the target of dissection (defined as most critical part of dissection,
requiring most attention and linked with max anxiety)
E.g. calot triangle , base of appendix, splenic artery/vein

Step II: Find the length of instrument

Neonatal………..20 cm
Pediatric……..28 cm
Adult………….36 cm
Morbid Obese………..45 cm
 How to get 1st Principle?

Step III: Draw the line of optimum area

Keeping target at center, draw 2 arcs

1st arc at 18 cm (half the length of instrument)

2nd arc at 24 cm (2/3rd of length of instrument)

All ports including telescope MUST ALWAYS be placed anywhere in between these
2 arcs.
 Second Principle of Baseball Diamond
Concept

Telescope should be in middle of working instruments i.e. Azimuth angle (defined

as angle between telescope and working port/hand instrument) must be equal i.e.
30o (normal range 15o to 45o)

i.e. contralateral port position

Etymology: Azimuth  Arabic al-sumūt, meaning "the directions"

 Rationale for 2nd Principle

Contralateral Port Position  Depth Perception

1. Linear
Parallax
 Rationale for 2nd Principle

2. Motion Parallax

Object near will appears to move more and vice versa

 Rationale for 2nd Principle

3. Relative Size

Object far will appears to be small and vice versa

 Rationale for 2nd Principle

4. Aerial gradient/persecption
Object near will appear to have better contrast and better color
 Rationale for 2nd Principle

5. Correct Shadow
 Rationale for 2nd Principle

6. Texture Gradient

Near object appears to have more rough and detailed surface

 Rationale for 2nd Principle

Versus ipsilateral port position

DEMERIT:
Less depth perception…….1 instrument too near to telescope and other away from
telescope.
Acceptable only for simple procedures such as appendectomy, ventral hernia
but doesn’t works for advanced surgery such as fundoplication, inguinal hernia repair,
hiatus hernia + knotting/suturing.
MERIT:
Allows sectorisation i.e. surgeon can move freely as camera is away from operative
 no physical contact between surgeon and camera holder
field
 Third Principle of Baseball Diamond
Concept

Manipulation angle(defined as angle between two working hand

instruments)should be 60o ± 15o
 How to get 3rd Principle?
Target of D issect ion

Barriatric Surgery
{45 cm l ong instrument)

Adult Surgery
(36 cm l ong i nstr
ument)

Telescope Pediatric Surgery

{28 cm long instrument)

Scm

7.5 cm
10cm
 How to get 3rd Principle?

Put tip of index finger over target of dissection

Put tip of thumb over site of telescope
Position of anatomical snuff box will give you rough estimation of secondary port
position in adult on both sides
Target of dissection

ANATOMICAL SNUFF BOX

Working port position

Optical port
 How to get 3rd Principle?

LIMITATIONS:

Not applicable for pediatric patients

Measurements are for average adult male surgeon………..in female reference point
is approximately radial styloid process
 SUMMARY

1st Principle: Half (i.e. 18 cm in adult) of the instrument should be in and half out so
that elevation angle is 60 degree.

2nd Principle: Contralateral port position with equal Azimuth angle is ergonomically
better

3rd Principle: Manipulation angle should be 60 degree.

Available at surgicalpresentations